General Clearance Form Accessibiity

Request for Approval under the “Generic Clearance for the Collection of
Routine Customer Feedback” (OMB Control Number: 3135-0130)
TITLE OF INFORMATION COLLECTION:
Design for Accessibility Needs Assessment Survey
PURPOSE:
This survey is being administered in the context of a Cooperative Agreement between the
National Endowment for the Arts and the Institute for Human Centered Design. The purpose is
to develop and implement a comprehensive and interactive Web site, called Design for
Accessibility, that integrates new and existing cultural accessibility resources.
This survey solicits information from a diverse range of target audiences within the arts and
cultural fields about their current staffing and training to meet responsibilities for ensuring equal
opportunities for people with disabilities. The survey asks how responsible parties are currently
finding information and technical assistance about accessibility in cultural environments and the
challenges they face in finding needed information. Finally the survey asks respondents to
identify features they would like to see on the Web site.
DESCRIPTION OF RESPONDENTS:
The respondents include State and Regional Arts Agencies, State Humanities Councils, State
Libraries, non-profit arts organizations, arts service organizations, and design trade
organizations. The recipients are executive directors and we anticipate that the actual
respondents will be a mix of executive directors, administrative staff, and designated 504/ADA
Coordinators in the organizations.
TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[ ] Customer Satisfaction Survey
[ ] Small Discussion Group
[X ] Other: _Web-based Survey

CERTIFICATION:
I certify the following to be true:
1. The collection is voluntary.
2. The collection is low-burden for respondents and low-cost for the Federal Government.
3. The collection is non-controversial and does not raise issues of concern to other federal
agencies.
4. The results are not intended to be disseminated to the public.
5. Information gathered will not be used for the purpose of substantially informing influential
policy decisions.
6. The collection is targeted to the solicitation of opinions from respondents who have
experience with the program or may have experience with the program in the future.
Name: Steven Shewfelt
To assist review, please provide answers to the following question:

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Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [X ] No
2. If Yes, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] No NA
3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No
NA
Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [X ] No

BURDEN HOURS
Category of Respondent

No. of
Participation
Respondents Time
366
15 minutes
366

Private agencies
Totals

Burden

92 hours

FEDERAL COST: The estimated annual cost to the Federal government is ___$0_________
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents
1. Do you have a customer list or something similar that defines the universe of potential
respondents and do you have a sampling plan for selecting from this universe?
[ X] Yes
[ ] No
If the answer is yes, please provide a description of both below (or attach the sampling plan)? If
the answer is no, please provide a description of how you plan to identify your potential group of
respondents and how you will select them?
The group includes the key state and regional organizations funded by the National Endowment
for the Arts, the National Endowment for the Endowment and the State Libraries. We will also
survey 24 arts and service organizations and request that they select six (6) pertinent members to
complete the survey. In addition, we are including six (6) pertinent committee chairs from the
American Association of Museums.
Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[ X ] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [ X ] No

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Please make sure that all instruments, instructions, and scripts are submitted with the
request.

Instructions for completing Request for Approval under the “Generic
Clearance for the Collection of Routine Customer Feedback”
TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request. (e.g. Design for Accessibility Needs Assessment)
PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.
If this is part of a larger study or effort, please include this in your explanation.
DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or
groups for this collection of information. These groups must have experience with the program.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.
Personally Identifiable Information: Provide answers to the questions. Note: Agencies
should only collect PII to the extent necessary, and they should only retain PII for the period of
time that is necessary to achieve a specific objective.
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide
a justification for the amount.
BURDEN HOURS:
Category of Respondents: Identify who you expect the respondents to be in terms of the
following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal
governments; or (4) Federal Government. Only one type of respondent can be selected per row.
No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g. fill out a survey or participate in a focus group)
Burden: Provide the Annual burden hours: Multiply the Number of responses and the
participation time and divide by 60.
FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents. Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes,
to the first question, you may provide the sampling plan in an attachment.

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Administration of the Instrument: Identify how the information will be collected. More than
one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or
facilitators (e.g., for focus groups) used.
Submit all instruments, instructions, and scripts are submitted with the request.

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